PHYSICAL EXAMINATIONNAME (LAST, FIRST, M.I.)

PLANT/DEPTDATE

EMPLOYEE NO.

AGESEXCIVIL STATUSPOSITIONHOME ADDRESS

NATURE OF EXAMINATION

PRE-EMPLOYMENTPERIODIC/ANNUALSPECIAL

(1) HEIGHT

(2) WEIGHT(3) APPEARANCE(4) TEMP(5) PULSE(6) B.P.

(7) VISIONNEAR

UNCORRECTEDNEAR

(R) (L) (B) FAR

(R) (L) (B)COLOR

(R) (L) (B)FAR

(R) (L) (B)COLOR

(8) HEARINGSTOPWATCH A.D.

A.S.

TUNING FORK A.D.

A.S.

(9) DENTALX-MISSING ( )-ARTIFICIAL 18 17 16 15 14 13 12 11 21 22 23 24 25 26 27 28

V-CARIOUS O-CAPPED 48 47 46 45 44 43 42 41 31 32 33 34 35 36 37 38

REMARKS:

(10) HEAD NORMAL

(11) EYES NORMAL

(12) EARS NORMAL

(13) NECK NORMAL

(14)

(15) BREAST NORMAL

(16) LUNGS NORMAL

(17) HEART NORMAL

(18) VASCULAR SYSTEM NORMAL

(19) LYMPHATICS NORMAL

(20) ABDOMEN & VISCERA NORMAL

(21) HERNIA NORMAL

(22) G.U. SYSTEM NORMAL

(23) ANUS AND RECTUM NORMAL

(24) ENDOCTRINE SYSTEM NORMAL

(25) UPPER EXTREMITIES NORMAL

(26) SPINE AND BACK NORMAL

(27) LOWER EXTREMITIES NORMAL

(28) OTHER MUSCULOSKELETAL NORMAL

(29) NERVOUS SYSTEM NORMAL

(30) SKIN NORMAL

(31) IDENTIFYING BODY MARKS NORMAL

LABORATORY

(32) URINALYSIS REACTION SP. GR. (33) ALB (34) SUGAR (35) MICROSCOPIC

(36) STOOL EXAM:

(37) BLOOD TYPE HGB RBC WBC POLYS LYMPH EOSIN MONO BASO

(38) ECG:

(39) CHEST X-RAY

(40) OTHER TESTS:

(41) UPDATE MEDICAL HISTORY

(42) RECOMMENDATIONS:

M.D

EXAMINEES SIGNATUREClassified - Internal useClassified - Internal useClassified - Internal use